PFD Response Tracker
Prevention of Future DeathsHow statuses are calculated — 56-day deadline, Judiciary.UK data
Recipients have 56 days to respond under Regulation 28. We use the deadline stated in the report where available, otherwise we calculate it from the report date.
We rely on Judiciary.UK for response data, so if a response has been provided but not yet published there, it may show incorrectly here.
"No identified response", "Pending", and "Historic" only count reports where no response at all has been identified as published on Judiciary.UK.
If at least one response has been published for a report, it counts as "Responded" — even if not every listed addressee has a separate published response.
This is because addressee data from Judiciary.UK can be unreliable: address fragments, job titles, and redacted names are sometimes parsed as separate addressees, and a single response PDF may cover multiple parties.
"Historic with no identified response" means we have not been able to identify a published response, but the report is more than two years old.
We do not mark these as overdue or pending because older reports may well have received a response that was simply never made public.
This is a neutral status indicating absence of an identified published record, not confirmed non-compliance.
Responded
Clear all
Filters
4,641 reports
· Page 34 of 93
| Date | Deceased | Addressee(s) | Status | Responses |
|---|---|---|---|---|
| 15 May 2023 |
Julie Hancock
Discrepancies between summary and full DVT prophylaxis guidelines led to a high-risk patient receiving inadequate treatment. A consultant's …
|
Royal Cornwall Hospital | All Responded | 1/1 |
| 15 May 2023 |
Raymond Lee
Limited national guidance and evidence exist for treating oesophageal strictures, particularly regarding the optimal number of dilatations versus …
|
NHS England National Institute for Health and … | All Responded | 2/2 |
| 15 May 2023 |
Rebekah Mills
Unclear clinical guidance on DVT risk reduction for young, immobile patients on oral contraception post-accident results in inconsistent …
|
National Institute for Health and … NHS England | Partially Responded | 1/2 |
| 15 May 2023 |
Rebecca Fisher
GMP officers failed to recognize high-risk missing person status due to poor understanding of mental health risks, misapplication …
|
Greater Manchester Police | All Responded | 1/1 |
| 14 May 2023 |
Thomas Huntley
Prison staff failed to comply with mandatory ACCT procedures and lacked understanding of risk factors, indicating poor training …
|
HM Prison and Probation Service | All Responded | 1/1 |
| 12 May 2023 |
Angela Craddock
An offender's Restraining Order was not communicated to prison staff, leading to breaches. Community rehabilitation services were unaware, …
|
HMP Altcourse HM Prison and Probation Service Ministry of Justice | Partially Responded | 2/3 |
| 12 May 2023 |
Tamsin Dolamore
High vacancies for detectives handling rape and serious sexual assault cases cause significant delays in securing best evidence, …
|
Network Rail Devon and Cornwall Police Police and Crime Commissioner | All Responded | 4/3 |
| 11 May 2023 |
Nicholas Pennicott
Persistent capacity issues and a three-year consultant vacancy in neurology led to long waiting times for outpatient appointments, …
|
NHS Improvement NHS England | All Responded | 2/2 |
| 11 May 2023 |
Julie Nolan
Limited documentation of wound management and pressure care raises concerns about adherence to care plans. Additionally, a single …
|
Maria Mallaband Care Group and … | All Responded | 1/1 |
| 10 May 2023 |
James Philliskirk
Junior staff failed to escalate concerns, exacerbated by unclear guidance on chickenpox reinfection, confirmation bias, and inadequate assessment …
|
Sheffield Children’s NHS Foundation Trust | All Responded | 2/1 |
| 10 May 2023 |
Mojeri Adeleye
There was a lack of regard for the mother's pregnancy knowledge and insufficient discussion with parents about potential …
|
Sheffield Teaching Hospitals NHS Foundation … | All Responded | 1/1 |
| 9 May 2023 |
Sandra Finch
Rigid ambulance categorization pathways incorrectly classify serious conditions, and an assessment team for lower priority calls without time …
|
NHS England and West Midlands … | All Responded | 1/1 |
| 7 May 2023 |
Bency Joseph
There was a significant delay and inadequacy in prescribing and administering therapeutic medication for psychosis, with family escalations …
|
Essex Partnership NHS Foundation Trust | All Responded | 1/1 |
| 5 May 2023 |
Joshua Asprey
Inconsistency between Sertraline's patient leaflet and the British National Formulary regarding suicidal behaviour side effects risks medical practitioners …
|
Royal Pharmaceutical Society National Institute for Health and … | All Responded | 2/2 |
| 4 May 2023 |
Helen Coogan
Missing qFIT test results for a patient with prolonged abdominal symptoms indicate a potential systemic issue requiring investigation, …
|
Ritchie Street Group Practice | All Responded | 1/1 |
| 3 May 2023 |
Sienna Barber
Lack of national guidance for diagnosing and treating Group A Streptococcus, particularly for high-risk groups like children under …
|
Royal College of Paediatrics and … National Institute for Health and … Department of Health and Social … | All Responded | 4/3 |
| 28 Apr 2023 |
Winbourne Charles
Failures in adequately assessing self-harm risk, unsupported reduction in observations, and suspension of observations prior to death. The …
|
North East London Foundation Trust Department of Health and Social … | All Responded | 2/2 |
| 27 Apr 2023 |
Milan Hamza
Lack of adequate signage to alert westbound drivers of a sharp left-hand bend and the adjacent water hazard …
|
Cambridgeshire County Council | All Responded | 1/1 |
| 27 Apr 2023 |
Caroline Forte
There is no clear pathway for sharing private psychiatrist consultation details and medication information with NHS Trusts, leading …
|
Royal College of Psychiatrists Sussex Partnership Foundation Trust | All Responded | 3/2 |
| 26 Apr 2023 |
Janet Smith
Insufficient staffing levels in the care home meant residents, including one requiring monitoring, were left unsupervised, leading to …
|
Silver Birches Care Home | All Responded | 1/1 |
| 26 Apr 2023 |
Colin Gumm
Significant failings in Adult Social Care oversight led to a vulnerable individual's self-neglect going unaddressed for years. A …
|
Lincolnshire County Council | All Responded | 1/1 |
| 26 Apr 2023 |
Nancy Price
The health board's internal investigations are too slow, with unrealistic action plans and missed deadlines, significantly delaying learning …
|
Betsi Cadwaladr University Local Health … | All Responded | 1/1 |
| 25 Apr 2023 |
John Roberts
A hospital inadvertently reduced a critical steroid dosage without informing the patient or GP. Additionally, national guidance (BNF/NICE) …
|
National Institute for Health and … Royal Cornwall Hospital Trust | All Responded | 2/2 |
| 24 Apr 2023 | Samuel Howes | NHS England Department of Health and Social … | All Responded | 2/2 |
| 21 Apr 2023 |
Amy Henderson
Delays in private hospitals accessing NHS records prevented crucial information, like prior ligature practice, from being immediately known. …
|
NHS England Priority Group | Partially Responded | 1/2 |
| 21 Apr 2023 |
Maria Shafighian
An inefficient internal postal system for communication between departments caused significant delays in escalating urgent changes in a …
|
Aneurin Bevan University Health Board | All Responded | 1/1 |
| 21 Apr 2023 |
Sarah Waller and Laura Pottinger
The absence of a barrier at the bottom of the weir, despite its hazardous re-circulating flow, particularly at …
|
Department for Environment, food and … Environment Agency | Partially Responded | 1/2 |
| 20 Apr 2023 |
Jodie McCann
Lack of comprehensive airway strategies, non-adherence to national algorithms/checklists, and inadequate daily checking of difficult airway equipment increase …
|
Derby and Burton NHS Foundation … | All Responded | 1/1 |
| 20 Apr 2023 |
Joseph Maunick
National care shortages force cognitively impaired patients into inappropriate Emergency Department settings, where severe staff and resource pressures …
|
NHS England Department of Health and Social … | All Responded | 2/2 |
| 20 Apr 2023 |
Chester Mossop
Bath seats create a false sense of security for parents, despite not being safety devices. There is a …
|
Office of Product Safety and … | All Responded | 2/1 |
| 19 Apr 2023 |
Elizabeth Hutchins
Critical cardiac symptoms, including an abnormal ECG and elevated troponin, were not acted upon, and the patient received …
|
Royal United Hospital | All Responded | 1/1 |
| 19 Apr 2023 |
David Mason
Clinicians across emergency, surgical, and pre-hospital care failed to recognise the need for additional steroid therapy for a …
|
West Midlands Ambulance Service University … NHS England National Institute for Health and … Association of Ambulance Chief Executives Worcestershire Acute Hospitals NHS Trust | All Responded | 6/5 |
| 18 Apr 2023 |
Keith Hodson
Failures in A&E triage, inadequate patient monitoring, and insufficient senior oversight led to missed opportunities to identify clinical …
|
Hereford County Hospital | All Responded | 1/1 |
| 18 Apr 2023 |
John Stiff
Insufficient ortho-geriatric provision for elderly patients with hip and pelvic fractures, despite repeated requests, risks future deaths due …
|
Department of Health and Social … Barking, Havering and Redbridge University … | Partially Responded | 1/2 |
| 18 Apr 2023 |
David Levett
The absence of safe parking areas, like hard shoulders, on an all-lane running smart motorway created a significant …
|
National Highways | All Responded | 1/1 |
| 15 Apr 2023 |
Sara Jones
A patient transfer occurred without a radiologist's report, which was then delayed in transmission and subsequently not acted …
|
Royal Stoke University Hospital and … | All Responded | 2/1 |
| 6 Apr 2023 |
Alexandra Briess
A critical lack of national systems for capturing and reporting anaphylaxis cases, especially fatal and near-fatal ones, along …
|
Department of Health and Social … Medicines and Healthcare Products Regulatory … UK Fatal Anaphylaxis Registry | Partially Responded | 2/3 |
| 4 Apr 2023 |
Thomas Jayamaha
Delayed progress in the Trust's Autism Strategy and complex case management, coupled with an unconvincing serious incident investigation …
|
Nottinghamshire Healthcare NHS Foundation Trust … | All Responded | 1/1 |
| 31 Mar 2023 |
Veronica Jenkins
A critical deficit in ambulance operational hours, stemming from staff shortages and hospital handover delays, significantly compromised patient …
|
Department of Health and Social … South East Coast Ambulance Service | All Responded | 2/2 |
| 30 Mar 2023 |
Carol Robinson
The patient was discharged from the Home Treatment Team without a medical review, comprehensive risk assessment, multi-disciplinary discussion, …
|
North East London Foundation Trust | All Responded | 1/1 |
| 29 Mar 2023 |
Rebecca Kirby
The Lowgate area poses a severe pedestrian safety risk on busy nights due to inadequate crossing facilities, dangerous …
|
Department for Transport Kingston Upon Hull Council Hackney Carriage Association for the … | Partially Responded | 1/3 |
| 29 Mar 2023 |
Angela Kearn
Medical profession lacks awareness of Immersion Pulmonary Oedema. Full face snorkel masks have inadequate safety standards and insufficient …
|
General Medical Council Decathlon UK Royal Society for the Prevention … National Trading Standards | Partially Responded | 2/4 |
| 28 Mar 2023 |
Louis Rogers
Inadequate management and investigation of febrile seizures, including insufficient parental information, deficiencies in paramedic guidelines, and GP assessment, …
|
Joint Royal Colleges Ambulance Liaison … NHS England Royal College of Emergency Medicine Royal College of General Practice National Institute for Health and … Royal College of Paediatricians | Partially Responded | 4/6 |
| 27 Mar 2023 |
Aoife McAdam
A patient prescribed a cardiotoxic medication for anxiety was not advised to safely dispose of it after switching, …
|
Burton Croft Surgery | All Responded | 1/1 |
| 26 Mar 2023 |
Jordan Clare
There is a critical, widespread gap in provision for vulnerable adults with complex needs outside existing social care …
|
Department of Health and Social … | All Responded | 1/1 |
| 24 Mar 2023 |
Richard Hill
Harmful alcohol consumption at grassroots rugby clubs, often involving mixed drinks, is exacerbated by a lack of specific …
|
Rugby Football Union | All Responded | 1/1 |
| 23 Mar 2023 |
Jade Revell
The SystemOne computer program risks abnormal blood test results being missed due to a minimised display, lack of …
|
TPP LTD | All Responded | 1/1 |
| 23 Mar 2023 |
Benjamin Nelson-Roux
The system failed to find suitable accommodation for a homeless 16-year-old by limiting searches to county boundaries and …
|
Department of Health and Social … North Yorkshire County Council Harrogate Borough council | Partially Responded | 2/3 |
| 22 Mar 2023 |
Kenneth Adams
The ambulance dispatch protocol (MPDS) inadequately prioritizes scalp lacerations in patients on antiplatelet/anticoagulant medication, failing to account for …
|
International Academics of Emergency Dispatch | All Responded | 3/1 |
| 17 Mar 2023 |
Benjamin Teague
The A5 road between Pottersbury and Paulesbury is in a very poor state with potholes, posing a highway …
|
National Highways | All Responded | 1/1 |
Julie Hancock
All Responded
Discrepancies between summary and full DVT prophylaxis guidelines led to a high-risk patient receiving inadequate treatment. A consultant's unawareness of comprehensive guidance raises concerns about …
Royal Cornwall Hospital
Raymond Lee
All Responded
Limited national guidance and evidence exist for treating oesophageal strictures, particularly regarding the optimal number of dilatations versus stenting and associated perforation risks.
NHS England
National Institute for Health …
Rebekah Mills
Partially Responded
Unclear clinical guidance on DVT risk reduction for young, immobile patients on oral contraception post-accident results in inconsistent approaches and failure to recognize fatal risks.
National Institute for Health …
NHS England
Rebecca Fisher
All Responded
GMP officers failed to recognize high-risk missing person status due to poor understanding of mental health risks, misapplication of "golden hour" guidance, and inadequate information …
Greater Manchester Police
Thomas Huntley
All Responded
Prison staff failed to comply with mandatory ACCT procedures and lacked understanding of risk factors, indicating poor training and audit quality. Inadequate information sharing between …
HM Prison and Probation …
Angela Craddock
Partially Responded
An offender's Restraining Order was not communicated to prison staff, leading to breaches. Community rehabilitation services were unaware, affecting risk assessment and recall procedures upon …
HMP Altcourse
HM Prison and Probation …
Ministry of Justice
Tamsin Dolamore
All Responded
High vacancies for detectives handling rape and serious sexual assault cases cause significant delays in securing best evidence, impacting both case quality and volume of …
Network Rail
Devon and Cornwall Police
Police and Crime Commissioner
Nicholas Pennicott
All Responded
Persistent capacity issues and a three-year consultant vacancy in neurology led to long waiting times for outpatient appointments, missing opportunities for earlier specialist assessment.
NHS Improvement
NHS England
Julie Nolan
All Responded
Limited documentation of wound management and pressure care raises concerns about adherence to care plans. Additionally, a single Registered Nurse was designated for two consecutive …
Maria Mallaband Care Group …
James Philliskirk
All Responded
Junior staff failed to escalate concerns, exacerbated by unclear guidance on chickenpox reinfection, confirmation bias, and inadequate assessment of skin lesions. GP referrals were also …
Sheffield Children’s NHS Foundation …
Mojeri Adeleye
All Responded
There was a lack of regard for the mother's pregnancy knowledge and insufficient discussion with parents about potential measures for premature labour before 22 weeks.
Sheffield Teaching Hospitals NHS …
Sandra Finch
All Responded
Rigid ambulance categorization pathways incorrectly classify serious conditions, and an assessment team for lower priority calls without time limits or prioritization creates dangerous delays.
NHS England and West …
Bency Joseph
All Responded
There was a significant delay and inadequacy in prescribing and administering therapeutic medication for psychosis, with family escalations ignored. The subsequent Trust investigation was also …
Essex Partnership NHS Foundation …
Joshua Asprey
All Responded
Inconsistency between Sertraline's patient leaflet and the British National Formulary regarding suicidal behaviour side effects risks medical practitioners being unaware of, or not discussing, this …
Royal Pharmaceutical Society
National Institute for Health …
Helen Coogan
All Responded
Missing qFIT test results for a patient with prolonged abdominal symptoms indicate a potential systemic issue requiring investigation, especially given the cause of death.
Ritchie Street Group Practice
Sienna Barber
All Responded
Lack of national guidance for diagnosing and treating Group A Streptococcus, particularly for high-risk groups like children under 5, and the absence of rapid antigen …
Royal College of Paediatrics …
National Institute for Health …
Department of Health and …
Winbourne Charles
All Responded
Failures in adequately assessing self-harm risk, unsupported reduction in observations, and suspension of observations prior to death. The emergency response was chaotic and staff records …
North East London Foundation …
Department of Health and …
Milan Hamza
All Responded
Lack of adequate signage to alert westbound drivers of a sharp left-hand bend and the adjacent water hazard creates a significant risk of future road …
Cambridgeshire County Council
Caroline Forte
All Responded
There is no clear pathway for sharing private psychiatrist consultation details and medication information with NHS Trusts, leading to a loss of critical patient history …
Royal College of Psychiatrists
Sussex Partnership Foundation Trust
Janet Smith
All Responded
Insufficient staffing levels in the care home meant residents, including one requiring monitoring, were left unsupervised, leading to a preventable fall and death.
Silver Birches Care Home
Colin Gumm
All Responded
Significant failings in Adult Social Care oversight led to a vulnerable individual's self-neglect going unaddressed for years. A Section 42 assessment was prematurely closed, missing …
Lincolnshire County Council
Nancy Price
All Responded
The health board's internal investigations are too slow, with unrealistic action plans and missed deadlines, significantly delaying learning and preventing the timely implementation of safety …
Betsi Cadwaladr University Local …
John Roberts
All Responded
A hospital inadvertently reduced a critical steroid dosage without informing the patient or GP. Additionally, national guidance (BNF/NICE) for Prednisolone lacks crucial information on bowel …
National Institute for Health …
Royal Cornwall Hospital Trust
Samuel Howes
All Responded
NHS England
Department of Health and …
Amy Henderson
Partially Responded
Delays in private hospitals accessing NHS records prevented crucial information, like prior ligature practice, from being immediately known. There was also staff confusion regarding responsibility …
NHS England
Priority Group
Maria Shafighian
All Responded
An inefficient internal postal system for communication between departments caused significant delays in escalating urgent changes in a patient's condition, specifically dysphagia, to the relevant …
Aneurin Bevan University Health …
Sarah Waller and Laura Pottinger
Partially Responded
The absence of a barrier at the bottom of the weir, despite its hazardous re-circulating flow, particularly at high water levels, poses a significant risk …
Department for Environment, food …
Environment Agency
Jodie McCann
All Responded
Lack of comprehensive airway strategies, non-adherence to national algorithms/checklists, and inadequate daily checking of difficult airway equipment increase patient risk. Failures in mortality review also …
Derby and Burton NHS …
Joseph Maunick
All Responded
National care shortages force cognitively impaired patients into inappropriate Emergency Department settings, where severe staff and resource pressures prevent adequate supervision and timely transfer, increasing …
NHS England
Department of Health and …
Chester Mossop
All Responded
Bath seats create a false sense of security for parents, despite not being safety devices. There is a concerning lack of national advice to healthcare …
Office of Product Safety …
Elizabeth Hutchins
All Responded
Critical cardiac symptoms, including an abnormal ECG and elevated troponin, were not acted upon, and the patient received no medical review for four days, indicating …
Royal United Hospital
David Mason
All Responded
Clinicians across emergency, surgical, and pre-hospital care failed to recognise the need for additional steroid therapy for a patient with Addison's disease after trauma. Trust …
West Midlands Ambulance Service …
NHS England
National Institute for Health …
Association of Ambulance Chief …
Worcestershire Acute Hospitals NHS …
Keith Hodson
All Responded
Failures in A&E triage, inadequate patient monitoring, and insufficient senior oversight led to missed opportunities to identify clinical priority. Delays in incident reporting and family …
Hereford County Hospital
John Stiff
Partially Responded
Insufficient ortho-geriatric provision for elderly patients with hip and pelvic fractures, despite repeated requests, risks future deaths due to inadequate recognition and treatment of co-morbidities.
Department of Health and …
Barking, Havering and Redbridge …
David Levett
All Responded
The absence of safe parking areas, like hard shoulders, on an all-lane running smart motorway created a significant safety risk for broken-down vehicles.
National Highways
Sara Jones
All Responded
A patient transfer occurred without a radiologist's report, which was then delayed in transmission and subsequently not acted upon by receiving doctors, highlighting a critical …
Royal Stoke University Hospital …
Alexandra Briess
Partially Responded
A critical lack of national systems for capturing and reporting anaphylaxis cases, especially fatal and near-fatal ones, along with no named accountability for allergy services, …
Department of Health and …
Medicines and Healthcare Products …
UK Fatal Anaphylaxis Registry
Thomas Jayamaha
All Responded
Delayed progress in the Trust's Autism Strategy and complex case management, coupled with an unconvincing serious incident investigation process, raise concerns about effective service improvement.
Nottinghamshire Healthcare NHS Foundation …
Veronica Jenkins
All Responded
A critical deficit in ambulance operational hours, stemming from staff shortages and hospital handover delays, significantly compromised patient safety through delayed response times.
Department of Health and …
South East Coast Ambulance …
Carol Robinson
All Responded
The patient was discharged from the Home Treatment Team without a medical review, comprehensive risk assessment, multi-disciplinary discussion, or communication with external agencies and family.
North East London Foundation …
Rebecca Kirby
Partially Responded
The Lowgate area poses a severe pedestrian safety risk on busy nights due to inadequate crossing facilities, dangerous taxi operations, and insufficient traffic management for …
Department for Transport
Kingston Upon Hull Council
Hackney Carriage Association for …
Angela Kearn
Partially Responded
Medical profession lacks awareness of Immersion Pulmonary Oedema. Full face snorkel masks have inadequate safety standards and insufficient public warnings regarding risks for users with …
General Medical Council
Decathlon UK
Royal Society for the …
National Trading Standards
Louis Rogers
Partially Responded
Inadequate management and investigation of febrile seizures, including insufficient parental information, deficiencies in paramedic guidelines, and GP assessment, contributed to missed opportunities for timely intervention …
Joint Royal Colleges Ambulance …
NHS England
Royal College of Emergency …
Royal College of General …
National Institute for Health …
Royal College of Paediatricians
Aoife McAdam
All Responded
A patient prescribed a cardiotoxic medication for anxiety was not advised to safely dispose of it after switching, leaving her with a significant, unneeded quantity …
Burton Croft Surgery
Jordan Clare
All Responded
There is a critical, widespread gap in provision for vulnerable adults with complex needs outside existing social care frameworks, leading to fragmented support and increased …
Department of Health and …
Richard Hill
All Responded
Harmful alcohol consumption at grassroots rugby clubs, often involving mixed drinks, is exacerbated by a lack of specific alcohol misuse guidance from the Rugby Football …
Rugby Football Union
Jade Revell
All Responded
The SystemOne computer program risks abnormal blood test results being missed due to a minimised display, lack of a scroll feature, and inability to prominently …
TPP LTD
Benjamin Nelson-Roux
Partially Responded
The system failed to find suitable accommodation for a homeless 16-year-old by limiting searches to county boundaries and lacking residential substance misuse treatment facilities for …
Department of Health and …
North Yorkshire County Council
Harrogate Borough council
Kenneth Adams
All Responded
The ambulance dispatch protocol (MPDS) inadequately prioritizes scalp lacerations in patients on antiplatelet/anticoagulant medication, failing to account for persistent bleeding or medication effects, leading to …
International Academics of Emergency …
Benjamin Teague
All Responded
The A5 road between Pottersbury and Paulesbury is in a very poor state with potholes, posing a highway safety risk that requires urgent attention and …
National Highways